TECHNIQUE OF OPEN END-TO-END ANASTOMOSIS

After exposing the posterior walls of the sigmoid stumps by means of Blllroth forceps (Fig. 171.5), the sur­geon unites them by No. 00 interrupted silk sutures (6— 8 sutures are applied). After tying the sutures, their ends are cut off except for the first and last which are left as stays.

The surgeon then applied a second posterior row oi interrupted sutures of No. 00 silk, with the needle inser­ted through the mucosa from the lumen side of one of the stumps and brought out to the lumen of the other stump (Fig. 171.6).

After tying all ligatures of the second posterior row, the surgeon cuts off the threads and turns his attention to the insertion of the anterior row of anastomotic sutures of interrupted fine silk to embrace all layers of the bo­wels being united (Fig. 171.7). The knots of these sutu­res are then tied from the serous coat side of the bowel.

Having cut the threads of the anterior row, the sur­geon removes the forceps and proceeds to apply, anteriorly, a second burying row of No. 00 silk sutures (Fig. 171.8) including the serous and muscular coats into them.

The anastomosis completed, the surgeon performes the cecostomy and carefully closes the mesenteric space by applying fine silk sutures to the periteneum on either side of the mesentery (Fig. 171.9). The second assistant then introduces a thick rubber tube into the sigmoid through the sigmoidostomy opening, with the surgeon pushing this tube, from the abdominal side to a site above the anas­tomosis.

The operation is completed by peritonealizing the me-sosigmoid bed using fine (No. 00) silk sutures. It should be remembered that after any type of colonic resection a most meticulous peritonealization of the colonic bed and of all other peritoneal defects should be undertaken to prevent the development of obstruction. Then the cecos­tomy must be made (fig. 153).

Fig. 171. Sigmoidectomy:

5. Application of the first row of posterior sutures of the end-to-end anastomosis between the sigmoid portions after resection.

6. Application of the second posterior row of sutures through all the layers of the walls of sigmoid segments being united.

7. Application of the anterior row of anastomosis su­tures.

8. Application of the anterior line of burying sutures.

9. Closing the space in sigmoid mesentery at the site of anastomosis; the tube passed through the anus (dot­ted line) is seen in the bowel.